The Role of Insurance Networks and Organizational Factors in Guideline-Concordant Care for Serious Mental Illness

项目摘要 严重的精神疾病影响了超过5%的美国人口，但只有一小部分 这些人都得到了适当的治疗。精神分裂症影响了百分之一的人口， 尤其是衰弱。精神分裂症患者的健康状况和社会后果都很差， 包括过早死亡、无家可归和滥用药物。精神分裂症患者在 自杀风险增加，并有高比例的共病。指南一致性护理（GCC）- 包括适当的药物和心理治疗-改善精神分裂症患者的预后， 包括死亡率。然而，GCC的发生率很低，在患者人口统计学中存在显著差异 组、临床条件和临床医生类型。虽然有些差异可能是由患者 偏好、保险和组织层面的系统因素可能导致GCC的低比率。 更好地了解系统因素-包括保险网络和组织的作用-有助于 引导治疗途径走向GCC并改善患者结局， 改善精神分裂症患者的临床实践。根据PAR-19-189的目标， 这项试点服务研究的目的是确定与获得和 心理健康服务的质量。使用全面的健康保险登记和索赔数据， 马萨诸塞州，我们量化和检查精神分裂症患者保险网络的变化，检查 这些网络特征的关联-包括大小和组成（反映心理可用性） 健康临床医生）-与患者的结果，指南一致的护理接收和自我伤害。作为一个潜在 了解保险网络如何影响患者结果的机制，我们研究 组织特征的关联-组织规模和精神卫生临床医生的比例- 患者的结果。我们进行了敏感性分析，仅限于由于以下原因而导致首次精神病发作的个体： 全面护理的临床紧迫性和对该人群的政策兴趣，并建立因果关系 保险网络和组织之间的关系以及使用年轻成人样本的结果。 了解与海湾合作委员会和成果相关的因素将有助于确定有效的政策杠杆， 在乎这项试点研究的结果将指导未来改善心理健康服务的提供，以及 确定今后研究影响关键系统特征的政策变化的途径。

PROJECT SUMMARY Serious mental illness affects more than 5% of the United States population, but only a small proportion of these individuals receive adequate treatment. Schizophrenia impacts one percent of the population and is particularly debilitating. Individuals with schizophrenia have high rates of poor health and social outcomes, including premature mortality, homelessness, and substance use. Individuals with schizophrenia are at increased risk of suicide and have high rates of comorbid disease. Guideline-concordant care (GCC) – including appropriate medications and psychotherapy – improves outcomes for individuals with schizophrenia, including mortality. However, rates of GCC are low, with significant variation across patient demographic groups, clinical conditions, and clinician types. Although some differences may be explained by patient preferences, system factors at the insurance and organization levels likely contribute to low rates of GCC. Better understanding system factors – including the role of insurance networks and organizations – that help guide treatment pathways towards GCC and improve patient outcomes is an important contribution to improving clinical practice for individuals living with schizophrenia. Pursuant to the goals of PAR-19-189, the objective of this pilot services research is to identify mutable health care system factors related to access and quality of mental health services. Using comprehensive health insurance enrollment and claims data from Massachusetts we quantify and examine variation in insurance networks for those with schizophrenia, examine associations of these network characteristics – including size and composition (reflecting availability of mental health clinicians) – with patient outcomes of guideline-concordant care receipt and self-harm. As a potential mechanism for understanding how insurance networks may influence patient outcomes, we examine associations of organizational characteristics – organization size and proportion of mental health clinicians – with patient outcomes. We conduct sensitivity analyses limiting to individuals with first episode psychosis due to the clinical urgency of comprehensive care and policy interest in this population, and establish a causal relationship between insurance networks and organizations and outcomes using a young adult sample. Understanding factors associated with GCC and outcomes will help identify effective policy levers to improve care. Findings from this pilot study will guide future improvements in mental health services delivery, as well as identify avenues for future research on policy changes influencing critical system characteristics.